Glocal is global: reimagining the training of global health students in high-income countries
Authors: Sonia S Anand, Madhukar Pai
Journal: The Lancet Global Health (2023)

Traditionally, training students in global health from high-income countries (HICs) has focused mostly on health problems of the Global South, and on trainees travelling to low-income and middle-income countries (LMICs) for experiential learning or research to complement the theory they are taught. These experiences can be personally transformative and might also evoke a profound awareness of students' own privilege, forcing them to consider how they might spend their privilege. However, this saviourism model of the traditional training of global health students in HICs and the ethics of short-term global health missions is being increasingly critiqued.1Sayegh H Harden C Khan H et al.Global health education in high-income countries: confronting coloniality and power asymmetry.BMJ Glob Health. 2022; 7e008501Crossref PubMed Scopus (9) Google Scholar, 2Svadzian A Vasquez NA Abimbola S Pai M Global health degrees: at what cost?.BMJ Glob Health. 2020; 5e003310Crossref Scopus (31) Google Scholar, 3Banerjee AT Bandara S Senga J Gonzalez-Dominguez N Pai M Are we training our students to be white saviours in global health?.Lancet. 2023; 402: 520-521Summary Full Text Full Text PDF PubMed Google Scholar In today's post-globalisation world, we need to question whether travel to LMICs, or an exclusive focus on inequities in LMICs, should continue to be a core component of global health training in HICs. We posit that similar experiential learning and research opportunities exist within marginalised communities within HICs and that involving global health students in addressing such issues might help to produce a cadre of students who are immersed in thinking, working, and solving global as well as local problems. These problems might include challenges faced by immigrants, refugees, Indigenous and rural communities, and other marginalised groups. For example, the USA is a country that spends a lot on health, and yet life expectancy is falling.4Harper S Riddell CA King NB Declining life expectancy in the United States: missing the trees for the forest.Annu Rev Public Health. 2021; 42: 381-403Crossref PubMed Scopus (43) Google Scholar It is also the only large HIC without universal health coverage. Gun violence has become the leading cause of death among children,5Roberts BK Nofi CP Cornell E Kapoor S Harrison L Sathya C Trends and disparities in firearm deaths among children.Pediatrics. 2023; 152e2023061296Crossref PubMed Scopus (1) Google Scholar and Black women are three times more likely to die from a pregnancy-related causes than White women.6Petersen EE Davis NL Goodman D et al.Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017.MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429Crossref PubMed Scopus (511) Google Scholar Erosion of reproductive rights and the proliferation of abortion bans will make this occurence worse.7Krieger N Structural racism, health inequities, and the two-edged sword of data: structural problems require structural solutions.Front Public Health. 2021; 9655447Crossref PubMed Scopus (54) Google Scholar Should American global health trainees not focus on such critical issues, and actively fight for social justice and universal health coverage? In Canada, the rate of tuberculosis in Inuit communities is nearly 300-fold higher than in Canadian-born, non-Indigenous people.8Mant M Abonyi S Hackett P Colonial tuberculosis legacies and the Dynevor Indian Hospital (1908–34).CMAJ. 2023; 195: e496-e498Crossref PubMed Scopus (0) Google Scholar During the COVID-19 pandemic, newer immigrants of South Asian origin had higher infection rates of SARS-CoV-2 compared with the general population, in part due to their jobs as front-line, essential workers in the service industries characterised by lower wages and limited health benefits.9Anand SS Arnold C Bangdiwala et al.Seropositivity and risk factors for SARS-CoV-2 infection in a South Asian community in Ontario: a cross-sectional analysis of a prospective cohort study.CMAJ Open. 2022; 10: e599-e609Crossref PubMed Scopus (3) Google Scholar This higher infection rate was compounded by reduced access to COVID-19 testing and access to information in their native language. Strong advocates from the South Asian community, working together with public health agencies, recognised these barriers early on and succeeded in ensuring improved access to testing and vaccines. However, these breakthroughs came later in the pandemic, after the South Asian communities were severely affected. Similar experiences were reported in the UK and the USA.10Webb Hooper M Nápoles AM Pérez-Stable EJ COVID-19 and racial/ethnic disparities.JAMA. 2020; 323: 2466-2467Crossref PubMed Scopus (1462) Google Scholar, 11Bentley GR Don't blame the BAME: ethnic and structural inequalities in susceptibilities to COVID-19.Am J Hum Biol. 2020; 32e23478Crossref Scopus (53) Google Scholar The concept of glocalisation, or glocal, is not new. The term emphasises the interplay between global and local factors, and is used in business, sociology, and urban planning.12Kickbusch I Global + local = glocal public health.J Epidemiol Community Health. 1999; 53: 451-452Crossref PubMed Google Scholar Emphasising a glocal health programme offers numerous advantages, such as addressing local health challenges, providing training and capacity building within HICs to foster a deeper understanding of vulnerable and marginalised populations, and encouraging collaboration as allies to support newcomers' settlement and students' growth. This approach not only reduces travel, leading to planetary health benefits, but also mitigates HIC White saviourism attitudes.3Banerjee AT Bandara S Senga J Gonzalez-Dominguez N Pai M Are we training our students to be white saviours in global health?.Lancet. 2023; 402: 520-521Summary Full Text Full Text PDF PubMed Google Scholar Moreover, it potentially cultivates a passion for health equity and establishes a framework that shapes future careers. Also, HIC global health programmes earn credibility and authenticity when they pay attention to inequities everywhere, not just in LMICs. The glocal approach should not discourage students from HICs from engaging in LMICs. Rather, it is essential to ensure they are aware of all the health inequities and injustices within HICs, to learn to avoid reinforcing a sense of otherness, to recognise the power and privilege they have and how HICs might have actively contributed to the power imbalances in their field, and to give them the option of also working on health inequities within HICs. If they do choose to work in LMICs, then their approach should pivot from one of saviourism and charity to genuine allyship and solidarity.3Banerjee AT Bandara S Senga J Gonzalez-Dominguez N Pai M Are we training our students to be white saviours in global health?.Lancet. 2023; 402: 520-521Summary Full Text Full Text PDF PubMed Google Scholar, 13Pai M Disrupting global health: from allyship to collective liberation.https://www.forbes.com/sites/madhukarpai/2022/03/15/disrupting-global-health-from-allyship-to-collective-liberation/?sh=46786b154e62Date: March 15, 2022Date accessed: August 21, 2023Google Scholar Greater grounding of global health trainees in inequities within their home countries would address, in part, the need to decolonise our approaches to global health in which serious asymmetries of power and privilege exist.1Sayegh H Harden C Khan H et al.Global health education in high-income countries: confronting coloniality and power asymmetry.BMJ Glob Health. 2022; 7e008501Crossref PubMed Scopus (9) Google Scholar, 2Svadzian A Vasquez NA Abimbola S Pai M Global health degrees: at what cost?.BMJ Glob Health. 2020; 5e003310Crossref Scopus (31) Google Scholar, 3Banerjee AT Bandara S Senga J Gonzalez-Dominguez N Pai M Are we training our students to be white saviours in global health?.Lancet. 2023; 402: 520-521Summary Full Text Full Text PDF PubMed Google Scholar, 14Abimbola S Asthana S Montenegro C et al.Addressing power asymmetries in global health: imperatives in the wake of the COVID-19 pandemic.PLoS Med. 2021; 18e1003604Crossref PubMed Scopus (90) Google Scholar A glocal perspective can also be considered from the perspective of the community of focus, be it marginalised communities in HICs or communities in LMICs, by consideration of the local sociocultural, economic, and political realities to co-design solutions.15Holeman I Kane D Human-centred design for global health equity.Inf Technol Dev. 2019; 26: 477-505Crossref PubMed Scopus (90) Google Scholar For glocal to work, universities in HICs must start forging equitable, bilateral partnerships with local and regional community-based organisations and build stronger relationships with people with lived experience. The principle of nothing about us without us, which is commonly used when planning research in partnerships with Indigenous communities, applies in this case too. All local work should be undertaken in the spirit of allyship and deep respect for self-determination and agency of communities that are dealing with diverse challenges. Otherwise, local work might also become extractive and exploitative. In conclusion, we call on global health programmes in HICs to adopt the glocal model and teach students to address health disparities wherever they occur. The overarching goal of glocal health includes fostering a generation of students who have a deep understanding and commitment to reduce health disparities through community-engaged methods, who incorporate a fulsome understanding and broad exposure of the social factors which affect health, and who gain a first-hand exposure to the formation of long-term community partnerships and the practice of authentic allyship. This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on September 29, 2023 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on September 29, 2023 SSA serves as Associate Vice-President of Global Health and the Department of Medicine's Associate Chair of Equity and Diversity at McMaster University. She is supported by a Tier 1 Canada Research Chair in Ethnicity and CVD and a Heart & Stroke Foundation Chair in Population Health, and holds grants from the Canadian Institutes of Health Research. MP serves as an advisor to WHO, Stop TB Partnership, Bill & Melinda Gates Foundation, and Foundation for Innovative New Diagnostics. He is supported by a Tier 1 Canada Research Chair in Epidemiology and Global Health and has no financial or industry conflicts. Correction to Lancet Glob Health 2023; published online Sept 18. https://doi.org/10.1016/S2214-109X(23)00382-0Anand SS, Pai M. Glocal is global: reimagining the training of global health students in high-income countries. Lancet Glob Health 2023; published online Sept 18. https://doi.org/10.1016/S2214-109X(23)00382-0—In the Declaration of interest section of this Comment, the second sentence of Sonia S Anand's declaration should have read "She is supported by a Tier 1 Canada Research Chair in Ethnicity and CVD and a Heart & Stroke Foundation Chair in Population Health, and holds grants from the Canadian Institutes of Health Research". Full-Text PDF Open Access